We are collectively grappling and finding ways around the world to with the pandemic of the new coronavirus, called SARS-CoV-2, and its disease COVID-19. In India itself, 819 people have thus far tested positive, and late on March 24, Prime Minister Narendra Modi instituted a 21-day nationwide lockdown. Now, there is an eerie rush – of panicked buyers are stores selling essential products and of daily-wage labourers walking back to their hometowns from cities, both activities rendered lethally difficult as the lockdown has borne down with excessive force, forcing people to stay in their homes.
This calls for the deconstruction of the home as a concept. That is, how safe our ‘homes’ are both from the virus and from abuse, and the spread of infectious diseases among different social groups. The rationale to stay home is to defer the strain on the existing health infrastructure in India and the lockdown is for the sake of the country’s citizens – but there are worries that this will lead to further abuse, domestic violence and mental health issues.
In the absence of any pharmaceutical intervention, the only strategy against COVID-19 is to keep susceptible people from mixing with infectious people. Testing, reporting and diagnostics; social distancing and contact tracing; and information dissemination and public communications have enough attention in the media and public discourse for epidemiological terms to have entered the lingua franca.
Although studies of mathematical modelling, clinical trials and drug testing have received approvals and funding, there is still a huge gap that we are staring at, in terms of the unknowns. There remain a lot of epidemiological and health response challenges. For example, experts are yet to understand the transmission dynamics of the novel coronavirus, its reemergence, and how environmental aspects influence its spread, especially temperature. There is a sense that the Indian people were not so sure they would be affected because of India’s typically warm heat. There are also many questions about susceptibility to the virus, differences in infection rates across age groups, and about post-infection immunity.
At the same time, laboratory research has focused developing affordable and appropriate treatment options as well as rapid and accurate tests that can be deployed locally.
And as social scientists, policymakers and epidemiologists plan, design and implement mitigation measures to control the spread of COVID-19 and undertake efforts to ‘flatten the curve’, their cost-effectiveness, for instance of measures like travel restrictions and bans, lockdowns and impact on the public health infrastructure, still only have limited to evidence of effectiveness.
In short, the pandemic is a humanitarian disaster, novel in its impact and spread, requiring immediate and urgent measures (with limited evidence and data) to support policy measures and action. However, this is also okay. This shouldn’t be cause for panic; instead, decades of literature, work and experience on India’s disaster management front shows that even as recovery takes years, and a new normal begins to take shape, planning and policymaking informed by limited evidence is constantly challenging but still can be done through systematic and holistic approaches. So what parallels and lessons can we draw from disaster studies to strengthen the current health system response?
First and foremost, essential services will be disrupted, causing cascading failures. In low and middle-income countries, urban, informal settlements are breeding grounds for the spread of such infectious diseases, with lack of appropriate and adequate environmental health infrastructure and practices: safe drinking water, safe sanitation facilities, open spaces, proper drainage, and awareness and practices related to safe hygiene. The policy and state measures for infection control, namely lockdown and ban on population movement, can contain the spread of disease yet emerging needs of food, nutrition, education, health hygiene, access to clean drinking water and sanitation, as well as mental health will widen.
Although we have demographic and socioeconomic information, there are still gaps pertaining to planning a proper response. For example, although the Sustainable Development Goals in 2015 called for WASH1 in healthcare facilities, and experts developed guidelines and indicators, big data gaps remain on how hand hygiene is maintained in health facilities and how healthcare waste is managed. This emerges as a crucial challenge when hospitals across the country struggle to procure personnel protection equipment for the health staff, as well as inculcate good hand-hygiene and other practices amongst the staff.
Secondly, any disruption of routine services will directly impact the most vulnerable groups. Children, disabled, elderly and women are likely to be affected immediately, and severely, but dig deeper and there will be vulnerabilities across different social groups as well: labourers, daily wage earners, migrants, those with preexisting health conditions, etc. Their needs vary, their capabilities and social networks continue to deteriorate with lockdown measures and – again – there are likely to be gaps in our understanding of their nutritional, educational, water, sanitation and hygiene needs.
The burden of recovery will often fall on women, as data biases – as Caroline Criada Perez described in her book Invisible Women: Exposing Data Bias in a World Designed for Men (2019) – in drug trials and non-inclusion in response and recovery plans will only cause additional stress and mismanagement of the response and misappropriation of resources. Pregnant women were at higher risk of contracting Ebola due to their high levels of contact with health services and workers or die during childbirth.
Third, when a majority still defecate in the open, how can they isolate during the lockdown? In crowded spaces, people are forced to share accommodation and, when available, toilets. One of the biggest control measures is hand-washing, and with limited water supply and economic means to purchase soap. this continues to be a huge challenge. Data from 2017 shows that 50.7% of the rural population does not have basic hand-washing facilities, including soap and water. The corresponding figure in urban areas is 20.2% and 40.5% overall.
Fourth, the shutdown of schools and educational institutions, although laudable as effective infection prevention and control measures, has also been heralded as an opportunity for distance and online learning across the US, UK and Australia. Even in India, reports indicate possible growth in ed-tech, edu-content, e-learning, and entrepreneurship in the education sector. Measures range from postponement of classes to providing online content and self-exercises.
However, these measures will also exacerbate inequities in the education sector because private schools will invest in reproducing and delivering content online, as well as engaging with students. But public schools will grapple with limited opportunities and funding to ensure engagement with students and their families to not only enable their learning but also ensure their well-being. Besides unequal access to digital learning platforms, we also need to be prepared and undertake action to mitigate the consequences of school closures as well, including in the form of isolation, lack of adequate food and nutrition, parents’ inability to provide learning at home, gaps in childcare and eventual dropouts.
Finally, concerted efforts in health systems strengthening is urgent and essential to ensure smoother recovery. With the current pledge by the Centre to provide Rs 15,000 crore to enhance health infrastructure, we also need to closely monitor, collect vital information and predict future demands on delivery of routine services, enhancing the capacities of the workforce and ensure access to not only the medicines for coronavirus treatment but all other essential drugs.
Diarrhoea and acute respiratory infections are the two most common causes of morbidity and mortality. Patients with disabilities as well as non-communicable diseases require prolonged treatment and healthcare, which will be deprioritised as resources in hospitals and health centres are strained due to corona pandemic. Studies find that non-communicable disease treatment may either be neglected or inadequate in a humanitarian context if response is poorly planned and these diseases are not considered a priority.
Mental health services are crucial in this pandemic to cater to the needs of several preexisting conditions, those who are traumatised, survivors of domestic abuse, and sexual violence, or triggered and anxious due to the failures of the basic fundamental response to this pandemic. Being locked down at homes, with limited mobility and social network could be a contributing factor to depression and abuse.
As the health infrastructure finally becomes responsive to the dynamics of the situation, there is a need to assess, monitor and learn from these measures. Some key areas that need immediate attention and research include collecting information or a baseline of what are the socio-economic impacts of the pandemic and control measures, how are the existing hospital mitigation measures faring, and what are the crucial foreseeable gaps in health infrastructure.
Today more than ever, we must ponder on questions of collectivism in advocating for change in the systemic response versus individual acts of selfishness to protect oneself from getting infected by the virus. This debate is central to the governance of our policy and action. After all, the virus is lethal and without treatment at the time of writing, but most who are dying are dying due to the circumstances that led to the spread and lack of measures to control the infection.
Although confined to the safety of my home, I urge you all to stand in solidarity, to accept policies and action as they are served top-down but also to engage, communicate and amplify the needs and voices of those who continue to struggle for recovery.
Sneha Krishnan has a PhD in environmental engineering from the University College London, where she studied and implemented projects on the recovery and resilience of village water and sanitation systems after floods, cyclones and earthquakes in South Asia. She is founder of a firm on Environment, Technology and Community Health, and has extensive experience working with London School of Hygiene and Tropical Medicine (LSHTM) on nutrition and health systems in India and Bangladesh.
water, sanitation and hygiene↩